Extracorporeal Shock Wave Therapy (ESWT): Mechanisms, Applications, and Clinical Evidence in Musculoskeletal, Joint, and Spine Disorders

Introduction

Extracorporeal Shock Wave Therapy (ESWT) is a non-invasive treatment modality that utilizes acoustic pressure waves to stimulate healing processes in various musculoskeletal conditions. Initially developed for lithotripsy, ESWT has expanded its applications into orthopedics and rehabilitation medicine, offering therapeutic benefits in tendon injuries, joint disorders, and spinal pathologies.

Mechanisms of Action

ESWT exerts its therapeutic effects through several biological mechanisms:
• Mechanotransduction: The mechanical energy from shock waves is converted into biochemical signals, promoting cellular activities that facilitate tissue repair.
• Neovascularization: ESWT stimulates the formation of new blood vessels, enhancing blood flow and nutrient delivery to the affected area, thereby accelerating healing.
• Anti-inflammatory Effects: The therapy modulates inflammatory responses by downregulating pro-inflammatory cytokines, reducing inflammation and associated pain.
• Pain Modulation: ESWT may alter pain perception by affecting nerve conduction and reducing the sensitivity of nociceptors.
• Stem Cell Activation: The treatment encourages the migration and proliferation of mesenchymal stem cells, contributing to tissue regeneration.

These mechanisms collectively contribute to the regenerative and analgesic effects observed in clinical applications of ESWT.

A set of six painful joints, medical 3D illustration

Applications in Musculoskeletal Disorders

ESWT has been effectively utilized in managing various musculoskeletal conditions:
• Tendinopathies: Including lateral epicondylitis (tennis elbow), Achilles tendinopathy, patellar tendinopathy, and rotator cuff tendinopathy.
• Enthesopathies: Such as plantar fasciitis, calcific tendinitis, and greater trochanteric pain syndrome.
• Bone Healing: ESWT has shown efficacy in promoting osteogenesis and enhancing callus formation in cases of delayed union or non-union fractures.

Clinical studies have demonstrated significant improvements in pain reduction and functional outcomes in these conditions following ESWT.

Joint Disorders

In joint-related pathologies, ESWT has been applied with promising results:
• Knee Osteoarthritis: ESWT has been shown to alleviate pain and improve joint function in patients with knee osteoarthritis.
• Shoulder Calcific Tendinitis: The therapy aids in the resorption of calcific deposits and reduces pain, enhancing shoulder mobility.
• Temporomandibular Joint (TMJ) Disorders: ESWT has been explored as a treatment option, with studies indicating improvements in joint mobility and pain reduction.

These applications underscore the versatility of ESWT in managing joint disorders.

Spine-Related Conditions

ESWT has been investigated for its efficacy in treating various spinal conditions:
• Chronic Low Back Pain (CLBP): Systematic reviews and meta-analyses have reported that ESWT can significantly reduce pain and improve lumbar function in patients with CLBP.
• Facet Joint Syndrome: ESWT may provide pain relief and improve mobility in patients with facet joint-related back pain.
• Myofascial Pain Syndrome: The therapy has been used to alleviate trigger point pain and muscle tension in the back.

These findings suggest that ESWT is a valuable tool in the non-invasive management of spine-related disorders.

Advantages and Limitations

Advantages:
• Non-invasive and safe with minimal side effects.
• Short treatment sessions and recovery time.
• Cost-effective compared to surgical interventions.

Limitations:
• Optimal treatment protocols (e.g., energy levels, number of sessions) are still under investigation.
• May be less effective in severe degenerative conditions.
• Contraindications include coagulopathy, local infection, and malignancy at the treatment site.

Conclusion

Extracorporeal Shock Wave Therapy represents a promising non-invasive treatment modality for various musculoskeletal, joint, and spine disorders. Its multifaceted mechanisms of action contribute to tissue regeneration and pain relief, making it a valuable addition to the therapeutic arsenal in orthopedics and rehabilitation medicine. Ongoing research is essential to optimize treatment protocols and expand its clinical applications.

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References
1. Simplicio, C. L., et al. (2020). Extracorporeal shockwave therapy: Mechanisms in musculoskeletal regenerative medicine. ShockwaveNet.
2. Schmitz, C., et al. (2015). Mechanisms of shock wave therapy in musculoskeletal disorders. Bone & Joint Research, 4(3), 125–132.
3. Wang, C. J. (2012). An overview of shock wave therapy in musculoskeletal disorders. Chang Gung Medical Journal, 35(3), 197–210.
4. Kang, T. W., et al. (2020). The effectiveness of extracorporeal shockwave therapy for the treatment of knee osteoarthritis: A meta-analysis of randomized controlled trials. Medicine, 99(48), e23352.
5. Seco, J., et al. (2023). Effectiveness of extracorporeal shock wave therapy for chronic low back pain: A systematic review and meta-analysis. Journal of Orthopaedic Surgery and Research, 18(1), 198.
6. Notarnicola, A., & Moretti, B. (2012). The biological effects of extracorporeal shock wave therapy (ESWT) on tendon tissue. Muscles, Ligaments and Tendons Journal, 2(1), 33–37.

It is my privilege to welcome you to the 46th Annual Scientific Meeting of the American Academy of Neurological and Orthopaedic Surgeons. We are gathered here at the Hilton Palacio Del Rio for our annual educational program.

Our conference will provide information on a variety of Neurological, Orthopaedic and Spine related topics and I encourage you to review the information available on the meeting APP to learn all about the various speakers and their presentations. I am delighted that in this year’s program will include a number of speakers from San Antonio and the surrounding area. Joining us from UT San Antonio will be Prof. Cristian Gragnaniello, who will present Modern Management Strategies in Thoraco-Lumbar Trauma on Saturday morning. In addition, invited guest speakers, Drs. Jon-Cecil Walkes from Houston and Steven Cyr from San Antonio will contribute two fascinating lectures on Friday morning.

I am pleased that the International College of Surgeons, as our educational partner, has worked closely with our Scientific Organizing Committee to develop additional programming that is likely to be of interest to all surgical specialties. I encourage every member of the Academy to peruse the program and participate in as many sessions as possible to earn the maximum number of CME credits.

I hope you have a most enjoyable visit to the home of the Alamo during our annual meeting!

Lucia Zamorano, MD, FICS, FAANOS
Chair, American Academy of Neurological and Orthopaedic Surgeons

Welcome Letters

Michigan Brain & Spine Surgery Center is looking for Administrative and/or Clinical Assistant to join our team of highly dedicated professionals who are committed in providing top-quality patient care. The candidate should possess attributes that include excellent communication skills, time-management skills, self-motivation, and the ability to work independently and as a team to accomplish daily goals and objectives, as well as, treating all patients’ and co-workers’ in a professional, respectful manner.

Learn more about this opportunity

The Courage Awards annually recognize a person and their family who has been diagnosed with an Autism Spectrum Disorder and demonstrates great character and perseverance in living with the challenges of this disorder.

There will be two awards presented. One will recognize an individual, sponsored by Susan V. Swider and Oakland MRI. The other will acknowledge the individual and their family, sponsored by Dr. Lucia Zamorano and Michigan Brain & Spine Surgery Center. The award will be presented to the winners at the annual Ted Lindsay Foundation Celebrity Golf Outing on Monday September 12, 2022 at Detroit Golf Club, Detroit, MI.

Ted Lindsay Foundation support research and educational programs focusing on the cause and management of Autism Spectrum Disorders.

Obesity is associated with increased operating times and higher complication rates in many types of surgery. Its impact on robotic thyroidectomy however, is not well documented. The aim of this study was to investigate the relationship between body mass index (BMI) and robotic transaxillary thyroidectomy (RTAT). A retrospective review of prospectively collected data of all patients who underwent RTAT at Yonsei University Health System from October 2007 to December 2014 was performed. Patients were divided into three groups based on BMI (Group 1: BMI < 25, Group 2: BMI 25–29.99, Group 3: BMI ≥ 30), and compared. A total of 3697 patients were analyzed. No differences between the three groups were observed in clinicopathological factors, extent of surgery or length of stay. After multivariate analysis, only seroma and transient voice hoarseness were related to increasing BMI. Total operative time was significantly longer for Group 3 patients with less-than-bilateral total thyroidectomy (BTT), but was not significantly different for patients with BTT. Although obese patients undergoing RTAT have a slightly higher risk of seroma, transient voice hoarseness, and longer operative times, BMI did not influence the other important surgical outcomes of thyroidectomy. Therefore, obesity should not be a contraindication for performing RTAT.

Minimally invasive surgery (MIS) is an increasingly common technique used in most surgical practices because of advantages of smaller incisions, reduced pain, less blood loss, shorter length of hospital stay, and earlier return to work. MIS for cervical endocrine glands began in 1996 when Gagner performed the first endoscopic subtotal parathyroidectomy in a patient with primary hyperparathyroidism1. Subsequently in 1997, Huscher et al. described the first endoscopic right thyroid lobectomy2. Different endoscopic approaches have since been developed and performed worldwide for better cosmesis and avoidance of neck scars. Endoscopic techniques are however limited by rigid instruments that cannot articulate for more precise retraction and dissection of vital structures around the thyroid gland.

Our institution developed gasless, robotic transaxillary thyroidectomy (RTAT) in 20073. Since then, we have performed more than 5000 thyroidectomies using this technique, achieving results that are comparable in complication rates and oncological outcomes to standard open operation4. Some surgeons have, however, been skeptical that such good results are only possible because of favorable patient body habitus, as the Korean population is mostly within the normal BMI range, as opposed to patients from Western countries where the obesity rate is much higher. This difference was highlighted in the 2013–2014 National Health and Nutrition Examination Survey that reported a U.S. obesity rate (BMI ≥ 30 kg/m2) of 40.4% in females and 35.0% in males5. The obesity rate in South Korea as reported by the Korean National Health and Nutrition Examination Survey for the same period, was 4.3% for females and 5.3% for males6.

Despite the significantly lower obesity rate in South Korea, our department still manages a small number of obese patients. Given that few objective data are available on the relationship between obesity and surgical outcomes of patients undergoing RTAT, we, at the largest robotic thyroidectomy center in the world, investigated the impact of BMI on operative time, morbidity and long-term outcomes of RTAT at our institution.

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Dr. Lucia Zamorano is a very experienced neurosurgeon who has been in practice for more than three decades. Her acclaimed medical career began in her native Chile in 1980, when she graduated from Catholic University Medical School in the capital city of Santiago, where she also completed an internship and residency. Dr. Zamorano then moved to Germany, and completed a fellowship in Neurosurgery at the Free University of Berlin. After moving to the United States she completed a further fellowship at the Henry Ford Hospital in Detroit, Michigan.

Dr. Zamorano has an international reputation as a leading neurological surgeon, treating a wide range of conditions for patients of all ages. Conditions treated by her include spine disorders, acoustic neuromas, tumors of the brain and spine, pituitary tumors, and epilepsy. She is particularly known as an expert in minimally invasive brain surgery, skull base surgery, and spine surgery.

Alongside her practice as a neurosurgeon, Dr. Zamorano has enjoyed an acclaimed academic career. She currently serves as a Clinical Professor at the William Beaumont School of Medicine at Oakland University in Auburn Hills, Michigan, and has earned the coveted title of Fellow of the International College of Surgeons. She is also at the forefront of research into new neurosurgical techniques. Her undoubted expertise and important work in her field makes Dr. Lucia Zamorano a very worthy winner of a 2017 Top Doctor Award.

About Top Doctor Awards

Top Doctor Awards specializes in recognizing and commemorating the achievements of today’s most influential and respected doctors in medicine. Our selection process considers education, research contributions, patient reviews, and other quality measures to identify top doctors

Direct link:  https://www.prnewschannel.com/2017/09/05/expert-neurological-surgeon-lucia-zamorano-md-fics-is-to-be-recognized-as-a-2017-top-doctor-in-birmingham-michigan-2/

SOURCE:  Top Doctor Awards

Endoscopic Lumbar Fusion is the most Minimally Invasive Spine Surgery technique to perform a fusion and “it will revolutionize and change the ways we do fusions, minimizing the approach, causing less damage to normal structures and improving the biomechanical construct with better patients outcomes” Dr. Zamorano adds.

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The center includes four operating rooms, two procedure rooms, pre-operative and post-operative recovery areas and a large reception area. It is licensed by the State of Michigan and is fully accredited by the Joint Commission for Accreditation of Healthcare Organizations. Lakes Surgery Center is affiliated with National Surgical Hospitals.